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Stored blood from clinical trials helped researchers to make an important discovery about responses to immunotherapy.

Summary

Some patients who receive immunotherapy drugs called checkpoint inhibitors experience significant benefit in terms of tumor shrinkage and longer survival — but many do not. A new study suggests that measuring changes in the blood could help doctors determine whether a person is likely to benefit from these drugs.

Highlights

Scientists analyzed changes in the blood of patients with melanoma treated with the immunotherapy drug pembrolizumab (Keytruda®).

They identified a biomarker that, when adjusted for the amount of cancer present, was correlated with outcomes to treatment.

Having a blood-based biomarker could enable doctors to learn early on whether a treatment is working for a particular patient.

The greatest hurdle facing cancer immunotherapy today is understanding why the treatment works for only a subset of the people who receive it — between 20% and 40%, depending on the type of cancer and the particular drug. Several potential biomarkers that can predict a patient’s response to these drugs have been proposed, including the number of immune cells found in a patient’s tumor and the level of a molecule called PD-L1.

But measuring these two biomarkers requires tumor biopsies, and neither is a perfect indication of how well a person will do on immunotherapy.

A new study published in the journal Nature— the result of a collaboration between Memorial Sloan Kettering, the University of Pennsylvania, and the Parker Institute for Cancer Immunotherapy — provides evidence that the blood can be an important source of information regarding a patient’s response to this type of treatment. The team found that blood contains clues about who is responding and who isn’t. Examining those clues could one day help a doctor decide when it’s time to try a different therapy.

It’s Reinvigorating

In this study, researchers analyzed changes in the blood of 47 patients (18 from MSK, 29 from Penn) with stage IV melanoma who were treated with the PD-1-blocking drug pembrolizumab. In particular, the researchers looked for signs of “reinvigoration” among circulating immune cells called T cells. (When T cells are overworked, they become “exhausted” and lose their ability to fight cancer; immunotherapy drugs can reinvigorate these cells to help them keep fighting.)

The study authors found that the level of a particular protein made by these T cells was a useful predictor of the outcome to therapy, provided that doctors also took into account the amount of the patient’s cancer — essentially, the size and number of their tumors.

“The idea is that there is a relationship between the reinvigoration of the immune system and the amount of tumor that the patient is facing,” says Michael Postow, a medical oncologist at MSK and a co-author of the paper. “So if a patient has a small amount of tumor and a lot of reinvigoration, they are likely to do well. If the patient has poor reinvigoration and a lot of tumor, they are unlikely to do well — at least with PD-1-blocking drugs alone.”

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Dr. Postow suggests that this protein biomarker, when factored in along with other prognostic information, could one day provide doctors with a way to determine early on whether an immunotherapy treatment is working for a particular patient.

“The fact that we can gain useful information about a patient’s response to immunotherapy with just a simple blood draw is a really significant step toward having a biomarker that can guide treatment decisions,” Dr. Postow says. “We’re not quite there yet in terms of the blood telling us everything we need to know, but this study is a good reminder that the blood is an important area in which to look.”

A Freezer Full of Data

To home in on this biomarker, the team analyzed stored blood samples from patients who had been treated with pembrolizumab as part of early clinical trials, some dating back to 2012. It’s routine for patients in clinical trials to have blood collected, frozen, and stored. In this case, that stored blood proved to be a gold mine.

Researchers thawed the blood and then stained it with various antibodies to detect known markers of exhaustion and reinvigoration. One marker of exhaustion is PD-1 itself. PD-1 is a so-called immune checkpoint, a protein that acts as a kind of brake, or check, on immune cell activity. Immune cells make PD-1 as a way to shut themselves down after they’ve successfully controlled a threat — an infection, say, or a budding cancer. But cancer cells are sneaky and can sabotage this natural control mechanism by making a molecule that engages the PD-1 brake on T cells, shutting them down prematurely. That molecule is called PD-L1. Drugs that block either PD-1 (such as pembrolizumab or nivolumab [Opdivo®]) or PD-L1 (such as atezolizumab [Tecentriq®]) prevent the PD-1 brake from being engaged, allowing immune cells to either stay active for longer or even reawaken.

The fact that we can gain useful information about a patient's response to immunotherapy with just a simple blood draw is a really important step toward having a biomarker that can guide treatment decisions.

Michael A. Postowmedical oncologist

But how could researchers tell, just by analyzing blood, whether these PD-1-positive cells were being reinvigorated? The team found that the number of PD-1-positive T cells that were also making a protein called Ki67 rose dramatically in the weeks following treatment with pembrolizumab. From previous laboratory studies in mice, the researchers knew that Ki67 is a sign of actively dividing immune cells. So their finding then suggested that Ki67 might be an appropriate biomarker of T cell reinvigoration.

Indeed, the change in Ki67 after treatment was a good predictor of a patient’s ultimate outcome — but only when adjusted for the amount of disease. This result indicates that it’s the balance between the two variables that is important. (While 75% of all patients had a rising Ki67 level after treatment, only 38% clinically benefited.)

Mission Possible

The Nature paper is the first major publication to come out of the collaborative Parker Institute for Cancer Immunotherapy, of which MSK and Penn are both founding members. Launched in April 2016, the Parker Institute is the brainchild of serial tech entrepreneur Sean Parker and is led by UCSF immunologist Jeffrey Bluestone.

“I think this study is really emblematic of what Sean Parker and Jeff Bluestone envisioned for the Parker Institute,” says Jedd Wolchok, Chief of the Melanoma and Immunotherapeutics Service and Director of the Parker Institute at MSK. “It shows what can be accomplished when cancer centers pool their resources and join intellectual forces to answer common problems.” Dr. Wolchok was the principal investigator of the immunotherapy trial at MSK for which these blood samples were taken. His research has helped establish this immunotherapy approach, called checkpoint blockade. Study co-author Dr. Postow conducts research in Dr. Wolchok’s laboratory, in addition to seeing patients.

I think this study is really emblematic of what Sean Parker and Jeff Bluestone envisioned for the Parker Institute.

Jedd D. Wolchokmedical oncologist

At Penn, the study was led by E. John Wherry, an expert in the phenomenon of T cell exhaustion. The idea to combine forces on the study came from a conversation between Dr. Wolchok and Dr. Wherry at a conference. The two scientists recognized that their labs were working on similar problems, and both scientists had samples of stored blood that could be analyzed.

“John then reached out to me, and that’s kind of where this all came from,” Dr. Postow says. “It’s been a great collaboration.”

He adds, “I’m really glad they approached us because this study allowed us to take advantage of the blood that our patients so generously provided.”

This study was funded by grants from the National Institutes of Health, the Tara Miller Foundation, a German Research Foundation fellowship, the Penn Department of Medicine Measey Research Fellowship Award, the Melanoma Research Alliance, the Robertson Foundation/Cancer Research Institute Irvington Fellowship, the Ludwig Center for Cancer Immunotherapy, Swim Across America, the Conquer Cancer Foundation, and the Parker Institute for Cancer Immunotherapy.

Comments

Ron Pierce

May 17, 2017 • 2:04 PM

My wife was diagnosed with Large B-Cell primary diffuse CNS non-hodgkins lymphoma. We started a clinical trial in December utilizing a chemotherapy Methotrexate , Rituximab , and Temador after 2 months had another scan and the tumor grew back . We were then removed from the trial . We then went to Mass Gen for a second opinion and now she is on another clinical trial this time its an immunotherapy using Nivolumab. She had a scan 2 weeks ago and the doctors seem to think it is growing in which we get another scan on June 6th. If it is still growing she will be taken off that trial as well. My question is are there more clinical trials or recommendations on this type of cancer.

Dear Ron, we’re very sorry to hear about your wife’s diagnosis. If you would like to speak with someone at MSK about treatment options, including clinical trials, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment and best wishes to you and your wife.

John Reissner

May 25, 2017 • 2:11 PM

Does any of this offer any help in controlling recurrent Prostate Cancer thanks

Dear John,
Immunotherapies such as the one described in this blog are being tested in patients with prostate cancer, where they have shown promise. To find open clinical trials, we recommend you visit https://www.mskcc.org/cancer-care/clinical-trials/search. Thank you for your comment.

FrankJ

May 25, 2017 • 4:25 PM

Could this experiment treatment is good also to treat any phrase of prostates cancer ?

Dear Frank,
The immunotherapy drug discussed in this article, pembrolizumab (Keytruda) is approved for several types of cancer, but not specifically for prostate cancer at this time. However, several immunotherapy drugs, including this one, are being tested in patients with prostate cancer, where they have shown promise. To find open clinical trials, we recommend you visit https://www.mskcc.org/cancer-care/clinical-trials/search. Thank you for your comment.

Alan Holtzman

May 25, 2017 • 10:30 PM

Just started Keytruda as a treatment for merkel cell carcinoma, a nasty cancer. Hoping for good results. Interested in the blood test! Is there something I should be alerting my docs to look out for in the blood work? Please let me know.

Dear Alan,
The blood tests discussed in this article is still experimental and not being used standardly as part of regular blood work. But PD-1/PD-L1-blocking drugs have shown promise in Merkel cell carcinoma, and one was just approved by the FDA. Best of luck to you.

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